International Journal of Surgery Case Reports 114 (2024) 109163

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International Journal of Surgery Case Reports

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Case report

Variant of the terrible triad of the elbow, a CASE report with a review of
the literature
F. Lamnaouar *, A. Rajaallah, A. Rafaoui, A. Messoudi, M. Rahmi, M. Rafai
Traumatology and Orthopedic Department P32, CHU IBN Rochd University Hospital Center, Casablanca, Morocco

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: The terrible triad described by Hotchkiss in 1996 is a complex lesion of the elbow, following a
Elbow trauma combining forced valgus and external rotation. It is a lesion that puts the elbow at risk of developing
Terrible triad variants complications such as instability, stiffness, or synostosis of the proximal radio-cubital joint.
Column theory
Case report: We report the case of a patient who suffered a closed trauma to the right elbow following a fall onto
Ring theory
the palm of the hand with a valgus lateral rotation mechanism. The lesion assessment showed a B2 fracture of the
Complex dislocation fractures
Instability distal humerus (AO classification) with a line splitting the capitulum in the frontal plane, a type 3 coronoid
Stiffness process fracture (Morrey/Odriscoll classification), and a posterolateral elbow dislocation. The surgical treatment
followed the same principles as for the terrible triad, with a reconstruction of the lateral column by osteosyn­
thesis of the humeral palate, followed by an internal approach for osteosynthesis of the coronoid process, with
the restoration of a stable elbow without laxity in the frontal plane.
Discussion: On the basis of the lesion mechanism, column theory, and the schematization of the constituent el­
ements of elbow stability in a ring, certain lesions can be placed in the same box as the terrible triad of the elbow,
which also complies with the same therapeutic implications.
Conclusion: Our observation underlines the possibility of the existence of lesions other than those described by
Hotchkiss, which would have the same consequences: an unstable elbow with the risk of evolving into chronic
instability or stiffness and whose management accepts the same management.

1. Introduction
Complex fracture dislocation of the elbow is a challenging condition
and constitutes a diagnostic, therapeutic and prognostic problem. The
elbow is considered to be an unforgiving joint, given two major risks:
stiffness and instability [1]. The risk of stiffness is present due to its highly
congruent bony anatomy, its relatively confined joint space, its closely
stabilizing collateral ligament complex and the close relationship between
the surrounding muscles, which act as secondary stabilizers [2].
In the terrible triad, the energy dissipates along a very precise path,
described as Horii's circle, resulting in a fracture of the radial head, a
fracture of the coronoid process and a posterior dislocation of the elbow.
However, depending on the extent of the traumatic energy and the di­
rection in which it dissipates, lesions may affect other columns, giving
rise to additional or superadded lesions. The most frequent mechanism
is a fall onto the palm of the hand with a combination of axial and valgus
compression on the elbow and supination of the forearm in relation to
the humerus [3].
A clear understanding of the anatomy and biomechanics of the elbow
* Corresponding author.
E-mail address: foad.lam@gmail.com (F. Lamnaouar).
joint, in particular the multiple bony and ligamentous structures that
contribute to joint stability, is necessary for surgical management.
Restoring stability to allow early mobilization and avoiding stiffness are
the main aims of treatment [1].
2. Case report
The reporting of this work follows the SCARE checklist criteria [16],
ensuring adherence to guidelines for quality reporting in case series.
We report the case of a 28-year-old patient who fell from a motorbike
and landed on the palm of his right hand, resulting in trauma to the
elbow. On admission, he had total functional impotence, a swollen
elbow, and altered bony landmarks of the elbow, with no opening of the
skin and no downstream vascular or -nervous disorders. Radiological
findings: a dislocated fracture of the elbow combined with a fracture of
the distal humerus classified as B2, a fracture of the coronoid process
type 3 according to Morrey's classification with posterolateral disloca­
tion of the elbow (Fig. 1a). A reduction maneuver was attempted but
failed. On CT scan, the lateral column line detached the lateral

https://doi.org/10.1016/j.ijscr.2023.109163
Received 23 October 2023; Received in revised form 6 December 2023; Accepted 8 December 2023
Available online 15 December 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
F. Lamnaouar et al. International Journal of Surgery Case Reports 114 (2024) 109163

epicondyle and continued on the capitulum, creating a frontal line and a

type 3 fracture of the coronoid process according to Odriscoll's classi­
fication (Fig. 1b).
The patient was treated surgically on emergency using a lateral
Kaplan, which enabled the epicondyle fracture to be reduced proxi­
mally, and fixed with three screws (we didn't have a plate in our
disposition) with the re-establishment of the contact condyle- radial
head. A medial approach allowed osteosynthesis of the coronoid process
and reinsertion of the medial capsule-ligament plane using an anchor
which allows the repair of the collateral medial ligament. After osteo­
synthesis and reinsertion, the elbow was stable and free of valgus or
varus laxity, tested at 30 % flexion (Fig. 1c–d).
The immobilization was realized by an articulated orthosis, and the
recovery of the range of motion was started after the 4th week (Fig. 2)
with a satisfying radiologic control (Fig. 3).
The follow-up of the patient at 4 months revealed good evolution
with incomplete recuperation of the room of motion of the flexion-
extension [− 10◦ − 0◦ − 120◦ ] (Fig. 4) the mayo elbow performance
score was judged excellent >90, the patient did go back to his work as a
mason.

3. Discussion

The function of the elbow is to facilitate the positioning of the hand

in space through flexion extension. To enable this, the elbow has a
ginglymoid huméro-ulnar joint. The key structure is the coronoid pro­
cess, which is made up of 3 structures: the coronoid tubercle (sublime)
and two anterolateral and anteromedial facets. In addition to being a
capsulo-ligamentary insertion site, it forms a buttress that prevents
posterior dislocation of the elbow [1].
The humeroulnar joint is very congruent; however, according to
Kapandji [4], there is a predisposition to dislocation in extension either
by forces that exert a distraction because the arc formed by the ulnar Fig. 2. Clinical checkup 6 weeks after trauma.
incisure forms an arc inferior to 180◦ and that holding will fail in the

Fig. 1. a. Radiological assessment on admission b. 3D reconstruction of the dislocated elbow fracture c. External approach with osteosynthesis of the lateral epi­
condyle d. Internal approach with osteosynthesis of the coronoid e, f Control X-ray.

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F. Lamnaouar et al. International Journal of Surgery Case Reports 114 (2024) 109163

Fig. 3. The post operative X ray images of the patient.

Fig. 4. Extension at − 10◦ /flexion 140◦ measured 4 months after surgery.

absence of soft parts. Resistance will be provided by ligamentous and

muscular elements. On the other hand, there is also a predisposition to
dislocation by compressive forces, and resistance is provided by bony
elements such as the coronoid process and the radial head. These
compressive phenomena are the most often encountered in elbow dis­
locations [4].
The radial head is responsible for transmitting 60 % of axial stresses
and 30 % of resistance to valgus loads, while the medial collateral lig­
ament absorbs the majority of stresses due to physiological valgus ulna
Fig. 5. Fortress diagram of the stability elements of the elbow according to
and the action of periarticular muscles, which increase pressure on
Odriscoll [6].
articular surfaces [5]. Isometric flexion against resistance can generate
stresses equal to up to 4 times body weight [4].
Several biomechanical theories explain the elements responsible for side. The second is defined as an alternative mode of failure, where
elbow stability: injury to one of the elements of the ring must spare the element next
to it; for example, fracture of the coronoid process will protect the
- The fortress theory (Fig. 5) according to Odriscoll, where the stabi­ ulnar collateral ligament [7]. In the case of our patient, the alter­
lizing elements are divided into primary stabilizers, which are the native mode of failure explains that the fracture of the lateral epi­
huméro-ulnar joint, the medial collateral ligament, and the lateral condyle and the condyle protected the radial head.
external ligament, and secondary stabilizers, which are the radial In this circle, the stability of the elbow is considered to be ensured
head, the capsule and the periarticular muscles, which exert a by four columns. In elbow trauma, the greater the number of ele­
compressive effect on the joint. In the event of a coronoid lesion, the ments and possibly columns affected, the more the stability of the
radial head becomes a crucial element in stability, and it can only be elbow will be compromised [8]. Each of these columns is necessary
resected if the coronoid and the LLI are repaired [6]. to preserve stability and the arc of mobility [9]. Instability leads to
chronic decentralization of the joint. Over time, this results in
- In the second representation (Fig. 6), similar to the ankle and pelvic reduced mobility due to capsular and muscular contractures and
ring, the elements ensuring the stability of the elbow form a ring with arthrofibrosis [2].
two imperatives: the first is that any rupture of the circle at a given
point must most likely be accompanied by another on the opposite In 1992, O'driscoll carried out a detailed study of the dislocation
process, concluding that supination stress coupled with valgus stress led

3
F. Lamnaouar et al.
Fig. 6. The constituents of the four columns of the elbow [3].
to the rupture of the lateral collateral ligament and the posterolateral
part of the capsule, ending in dislocation. Based on these findings, Horii
and Odriscoll developed a theory of the “Horii circle”, similar to May­
field's diagram for the carpus, in which soft tissue damage occurs from
lateral to medial [10]. Three stages are then described (defined by the
spectrum of instability for O'driscoll) [11]:
- Stage 1: Partial or complete rupture of the lateral collateral
ligament = posterolateral subluxation
- Stage 2: Rupture of the anterior and posterior soft tissues =
complete dislocation of the elbow (pronated forearm stabilizes
the elbow by action of the LLU)
- Stage 3 is subdivided into three categories:
▪ 3A: Associated with a fracture of the radial head and coronoid/
anterior fascicle of the LLI intact: no subluxation during the
varus/valgus test
▪ 3B: The medial ligament complex is ruptured/the elbow is
unstable even after reduction. A certain degree of flexion is
necessary to maintain the reduced elbow (30 to 45◦ ).
▪ 3C: humerus stripped of all soft tissue/elbow unstable even
with 90◦ plaster cast immobilization. Flexion >90◦ is necessary
to maintain the reduced elbow [11].
For O'driscoll, the aim of treatment is to restore bone stresses and
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International Journal of Surgery Case Reports 114 (2024) 109163
thus convert the lesion into a simple dislocation [6].
The management of a terrible triad is currently codified [12,13,14]
and is based on the following principles:
- The risk of reluxation is reduced by fixation or replacement of the
radial head, reinsertion of the external collateral ligament on the
epicondyle, and, if necessary, repair of the coronoid process.
- Restoring capitulo-radial contact is a key element in restoring elbow
stability
- As long as the elbow remains reduced, the ulnar collateral ligament
will be able to heal.
- If repair of the coronoid, radial head, and external collateral liga­
ment does not prevent dislocation, repair of the medial collateral
ligament will be considered.
A review of the literature [3] looked at variants of the terrible triad.
The criteria for inclusion in the terrible triad category and its variants
were the mechanism of injury and the existence of associated ligamen­
tous injuries of the elbow and retained the article by Desai et al. [8] and
Kumar et al. [15], where the injury involved the capitulum and not the
radial head. Our team considered our observation to be an equivalent
lesion or a variant of the terrible triad, given:
F. Lamnaouar et al.
- The mechanism of injury combines valgus axial compression and
supination
- An injury to the inside of the external column that, according to the
ring theory, the injury to one element should protect the element
next to it.
- In the principles of treatment, the stabilizing element is the
capitellar-radial contact: the capitulum, like the radial head, also
constitutes a stabilizing element, the excision of which, associated
with an internal ligament injury, gives rise to laxity and instability of
the elbow.
4. Conclusion
The elbow is a joint that always poses problems from a therapeutic
point of view, particularly given its tendency to stiffen and the risk of
instability, especially in the case of complex dislocation fractures of the
elbow.
Despite the challenges posed by the terrible triad, a good application
of anatomical and biomechanical knowledge with the application of
basic surgical techniques can bring good results for patients [1].
The wide variety of lesions at this level should prompt us to consider
broadening the definition of the terrible triad, especially as management
is based on the same principles.
Consent
Written informed consent was obtained from the patient for publi­
cation of this case report and accompanying images.
Ethical approval
The case report is exempt from ethical approval at our institution,
and only consent is necessary.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
All the authors contributed to the study concept, data analysis and
writing of the paper.
Guarantor
Dr. Foad Lamnaouar.
International Journal of Surgery Case Reports 114 (2024) 109163
Declaration of competing interest
The authors declare no conflict of interest.
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